Surgery Consent Form – Chester Valley Veterinary Hospital

Your Name *

First

Last

Pet's Name *

Email *

Pet's Name

Pet's Breed

Pet's Date of Birth

Single Reason for Visit *

Excessive Thirst? *

Yes
No

How Long has This Been Happening? *

Discharge from Eyes? *

Yes
No

How Long has This Been Happening? *

Squinting eyes? *

Yes
No

How long has this been happening? *

Has your Pet Been to the Lower 48? *

Yes
No

When? *

Was Pet on Preventatives? *

Yes
No

Does your Pet Have Diarrhea? *

Yes
No

What Kind of Diarrhea? *

Liquid
Soft
Bloody

How Long? *

How Often? (copy) *

Is Your Pet Vomiting? *

Yes
No

What Kind of Vomit?

Food
Water
Bile
Other

How Long? *

How Often? *

Does Your Pet Have Excessive Drooling? *

Yes
No

How Long? *

Does Your Pet Have Foul Breath? *

Yes
No

How Long? *

Is Your Pet Experiencing Lame Liming? *

Yes
No

How Long? *

Is Your Pet Lethargic? *

Yes
No

How Long? *

Does Your Pet Have Difficulty Urinating? *

Yes
No

How Long? *

Has Your Pet Experienced Weight Gain/Loss? *

Yes
No

How Long? *

Is Your Pet Eating/Drinking Well? *

Yes
No

How Long? *

Is Your Pet Experiencing Excessive Urination? *

Yes
No

How Long? *

Is Your Pet Experiencing Poor Balance? *

Yes
No

How Long? *

Is Your Pet Experiencing Pain? *

Yes
No

How Long? *

Has There Been Change in Urine? (Color/Odor) *

Yes
No

How Long? *

Has There New or Unusual Lumps? *

Yes
No

Where? *

How Long? *

Are There Any Wounds? *

Yes
No

Where? *

When Did it Happen? *

Has your Pet Experienced Inappropriate Urination? *

Yes
No

How Long? *

Is Your Pet Experiencing Balding/Losing Hair? *

Yes
No

How Long? *

Where? *

Is Your Pet Experiencing Excessive Panting? *

Yes
No

How Long? *

Does Your Pet Have Dirty/Smelly Ears? *

Yes
No

How Long? *

Is Your Pet Experiencing Sneezing/Coughing/Hacking? *

Yes
No

How Long? *

Is Your Pet Experiencing Labored Breathing/Wheezing? *

Yes
No

How Long? *

Is Your Pet Scratching Ears/Shaking Head? *

Yes
No

How Long? *

Is Your Pet Current on Rabies? *

Yes
No

*Must be able to provide proof today.

Additional Information (Destination Address for a Health Certificate to travel) etc.

Any Additional Medications or Supplements

Has your pet been given any medications in the last two-four weeks?

Yes
No

When were the medications last given?

Recent Emergency Visits? Where Was Your Pet Seen?

Do you think it is possible that your pet will bite or injure you while in the vet clinic? Please let us know so we can have staff prepared to help. *

Yes
No

Do you feel that your pet may bite or injure a staff member while at the vet? Please let us know so that we can keep all staff and animals safe. *

Yes
No

Do you have any physical limitations that would cause you to be unable to handle your pet inside the clinic? Please let us know so we can have staff prepared to help. *

Yes
No

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Primary Contact Today (Name) *

Primary Phone Today *

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. *

I have read and agree.

I acknowledge that my pet is scheduled for an anesthetic procedure. I have been informed that advances in anesthesia and anesthetic monitoring techniques have made routine procedures relatively safe, with low rates of complications. However, I understand that occasionally problems can occur due to pre-existing conditions that are not evident during routine histories and physical examinations. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital. *

I have read and agree.

To minimize problems the doctors and staff at Chester Valley Veterinary Hospital have recommended that my pet be screened prior to anesthesia. *

I Consent to the recommended pre-anesthetic diagnostics.
I Decline to the above recommended pre-anesthetic diagnostic test and in the absence of negligence, agree to hold the attending doctor(s) and staff at Chester Valley harmless for any untoward anesthetic, surgical, or medical complications that might have been detected and avoided had these tests been performed.

Has your pet had any medications today? *

Yes
No

Please list all medications taken, when they were taken, and how much was given. *

Has your pet had any food or treats in the past 12 hours? *

Yes
No

Please list all food brands given, when they ate, and how much they ate. *

I hereby certify that I am the owner or authorized agent of the above-named animal and have the authority to execute this consent. *

I have read and certify.

Signature *

Clear Signature

Date *